Community Health Service
REFERRAL FORM	UR / MRN:
Surname: <PtSurname>
Given Names: <PtFirstName>
Preferred Name: <PtPrefName>
DOB:  <PtDoB>                 Gender: <PtSex>	
Date of Referral: <TodaysDate>	Referring Health Agency: <Practice>	
Client Aware of Referral: <Client aware of Referral>	Form Completed By:<RefName>	
Client Consent Given: <Client Consent for Referral>	Position: <Referrer role in Care>	
Guardianship of the Minister: <Client in Guardianship of the Minister>	Tel: <RefPhone>	Fax:<RefFax>	
REFERRING HOSPITAL (If referral is from Hospital please complete the following section)	
Patient Requires: <Referral from Hospital>	
Admission Date: <Hospital Admission Date>	Hospital Ward: <Hosptial Ward>	
Discharge Date: <Hospital Discharge Date>	Hospital Medical Record:<Hospital Record Number>	
Follow Up GP/ Outpatient Appointment Date: <Follow up GP appointment>	Required Service Date: <Required service start date>	
CLIENT INFORMATION                                                             INDIVIDUAL HEALTH IDENTIFIER: <PtIHI>	
Title: <PtFormalName>	Marital Status:  <PtMaritalSt>	
Residential Address: <PtAddress>	
Postal Address: <PtPOAddress>	
Home Tel: <PtPhoneH>	Work Tel: <PtPhoneWk>	Mobile Tel: <PtPhoneMob>	
Aboriginal / Torres Strait Islander: <PtEthnicity>	Interpreter required: <Interpreter required>	
Country of Birth: <Country of Birth>	Language Spoken at Home: <Language preferred>	
Private Health Insurance:  <PtInsFund>       <PtInsNo>          Extras Cover:  <Extras Cover needed>
Ambulance Cover: <Ambulance Cover>	
Regular GP: <Regular GP>
GP/ Medical Clinic: <Practice>	

Pre-Existing GPMP: <Pre exisiting GPMP in place>	

	Allergies /Infectious Conditions: <Reactions>	
Pre- Existing TCA: <Pre exisiting TCA in place>	

Pre-Existing Service Providers: <Pre exisiting Service providers>	

	Known Hazards for Home Visits: <Known hazards for Home visits>	
Medicare Card#:  <PtMCNo>                 Individual Reference #:      <PtMCLine>                              Expiry: <PtMCExpiry>	
Concession Card #:<PtPensionNo>  <PtDVANo>	Type:        <Concession Card Type>                                                    Expiry:	
National Disability Insurance Scheme#: <NDIS Number>	Compensable: <NDIS Compensable>	
Client Lives: <Client lives>	Client Has Carer: <Client has Carer>	
Advance Care Directive: <Does Client have Advance Care Directive>	Client Lives with Carer: <Client has Carer>	
EMERGENCY CONTACT/ GUARDIAN/ CARER/ SUBSTITUTE DECISION MAKER	
Name: <NOKName>	Relationship: <NOKRelation>	
Address: <Next of Kin Address>	
Home Tel: <NOKContact>	Work Tel:<NOKContact2>	Mobile Tel:	
CLINICAL DETAILS	
Medical History (Primary and Secondary Diagnosis / Current recent Hospital admissions details) 
<PMHActive>	
Presenting Problem: 
<TodaysVisit>	
Medication List:
<CurrentRx>	
Management/ Care Requested (Reason for referral request for Service type and care needed)
<Type of Service requested>
<Details of service requested>
 	
Fax Completed form to: 08 8682 5831
Telephone: 1800 003 307
Country Health Referral - Port Lincoln Community Health 	Office Use Only

PL